FEATURED ARTICLES: REVENUE CYCLE MANAGEMENT

Consumerism has been driving industry improvements for many years, but its impact on hospitals and health systems remains fairly new. Patients with high deductible health plans (HDHPs) continues to rise. Ten or so years ago, only 55 percent of plans even had a deductible.

When was the last time you used a check to pay for anything? I can’t remember the last time I used a paper check. Was it five or 10 years ago? I’m not entirely sure. But one place checks are still in use is at your doctor’s office. And it has to stop. Really. What was once a convenient payment method is now antiquated and should be retired as digital payments have become ubiquitous and secure.

Over the past decade, the patient payment experience in healthcare has changed drastically, often at the cost of the patient experience. If a patient was insured, going to the doctor meant paying a $20 to $50 copay, with the insurance company handling the rest. Providers had the option to then collect the copay or just as easily write off that $50.

CASE STUDIES & WHITE PAPERS

In the continuing effort to increase quality and decrease costs, health plans and providers are shifting from volume-based care (fee for service) to a value-based reimbursement structure (fee for value). Value-based reimbursement promises benefits to patients, providers, and health plans, as it encourages delivery of high quality care at the lowest cost, largely by improving clinical and administrative efficiency.

Caradigm recently conducted a survey of healthcare organizations in order to better understand how providers are approaching bundled episodes of care. Although some providers have been piloting bundled episodes for several years, most are still in the early stages of refining their strategies and increasing their participation in The Centers for Medicare and Medicaid Services (CMS) Bundled Payment for Care Improvement (BPCI) program.

We may look back on the 25-year span following the change of the millennium as one of the most densely populated periods of healthcare regulation ever seen in the history of the United States. Every year, individual clinicians, private practices, and health systems are bombarded with new coding, compliance, quality, and reimbursement models, making staying ahead of the curve in terms of overall strategy nearly impossible. Executives, physicians, and healthcare experts would probably agree that it is impossible to maintain a status quo level of performance if your strategy is one of pure reaction to each new deadline from the Department of Health and Human Services.

FROM THE EDITOR'S DESK

Many industry leaders championed a free market approach to healthcare during the 12th Annual World Health Care Congress last week. Here are a few key reasons why I don’t think this model is “the fix” our industry so desperately needs.

RCM (REVENUE CYCLE MANAGEMENT)

At its core, revenue cycle management (RCM) is the process that ensures healthcare providers are efficiently reimbursed for the services they provide. The most significant parts of the process includes tracking patient claims, collecting payment for each claim, and handling claims that are denied for various reasons. To accomplish this goal, RCM systems must tightly integrate claims data, clinical data and IT infrastructure.

RCM systems track patients’ interactions with providers as they enter a hospital or arrive for a scheduled physician’s appointment. From that initial contact point, the RCM system tracks claims at every point on its way to resolution. This allows the process to be monitored by providers and gives them the ability to address any issues or delays that might arise. This RCM transparency ensures a steady revenue stream for healthcare providers.